Montana Board Of Medical Examiners

Montana Board of Medical ExaminersPO Box 200513301 S Park, 4th FloorHelena, MT 59620-0513Phone: 406-444-6880Email: DLIBSDHELP@MT.GOV Website: EMT.MT.GOVLicensing Requirements and Application ChecklistEmergency Care Provider (EMR, EMT, AEMT, Paramedic)License Requirements for Emergency Care ProviderBelow are the minimum requirements you must meet in order to be licensed in the state of Montana.1.2.3.4.Age 18 or older – [MCA 50-6-203, ARM 24.156.2711]High school diploma or equivalent [MCA 50-6-203, ARM 24.156.2711]Completion of a course of ECP instruction – [MCA 50-6-203, ARM 24.156.2711]NREMT or passage of a written and practical exam approved by the Board, or current EMR, EMT,AEMT or Paramedic licensure in another state in which applicant orignally tested and has acomplaint process.-[MCA 50-6-203, ARM 24.156.2711]5. NPDB SELF QUERY (National Practitioner Data Bank)Checklist of Required Documents to Submit for Application for Emergency Care ProviderThe following documents and additional forms are required in addition to the basic application. State licensureverifications must be sent to the board directly from the source. Official license verification from states and jurisdictions in which the applicant holds or has ever held aprofessional license of any type. Verification of course completion. Proof of a current NREMT card at or above the level of licensure sought OR proof of passing theMontana written and practical exams at or above level of licensure sought OR a current unrestrictedlicense or certifcation at or above the level of licensure sought, in another state in which the applicantwas originally tested and which has a complaint process. If you answered yes to discipline questions, include a detailed explanation on the event(s) anddocumentation from the source (licensing board, federal agencies/programs, or civil/criminal courtproceedings such as initiating/charging documents, sentencing documents, final disposition/judgmentdocuments, etc.)Application Fee(s) for Emergency Care ProviderThe following fee(s) must be submitted with your application. Online applicants can pay using a credit card ore-check. If you submit a paper application you must submit a check. Do not mail cash. 30 application fee for EMR 50 application fee for EMT 70 application fee for Advanced EMT 100 application fee for ParamedicPage 1 of 2ECP ChecklistUpdated 10/29/2019

You can apply for a license online at EBIZ.MT.GOV/POL or download a paper application from thewebsite. Online application is recommended.Please include a valid e-mail address with your application. E-mail is the department's primary form ofcommunication.If you have any questions about the application process or the licensing requirements please contactthe Department of Labor and Industry Professional Licensing Bureau using the contact information atthe top of this checklist.Page 2 of 2ECP ChecklistUpdated 10/29/2019

ECP app 6 Revised 07/19Page:1 of 8MONTANA BOARD OF MEDICAL EXAMINERSPO Box 200513301 South Park Avenue 4th FloorHelena, Montana 59620-0513PHONE: 406-444-6880 FAX: 406-841-2305E-MAIL: DLIBSDHELP@MT.GOV WEBSITE:EMT.MT.GOVNOTE: II DSSO\LQJ ZLWK VWDWH OLFHQVXUH ZLWKRXW 15(07 FHUWLILFDWLRQ \RX PXVWVXEPLW SURRI WKDW \RX WRRN DQ 15(07 HTXLYDOHQW H[DPLQDWLRQ WR REWDLQ OLFHQVXUHLQ WKDW VWDWH Licenses granted via reciprocity with other states will not beconsidered.NOTE: Montana ECP licensees applying for another level of licensure mustsubmit the following v Current active or inactive NREMT card equal to or greater than the level sought.PROCESSING PROCEDURES FOR ALL APPLICATIONS: An application file must be complete before consideration of licensure.The applicant will be notified in writing of any items missing from theapplication file. An application typically takes 10 working days to process from the time it iscomplete. If the application is considered a non-routine application, there may be adelay in processing of the application. You may be requested to provide additional information, contact theMontana Professional Assistance Program and/or make a personalappearance before the Board during a regularly scheduled Board meetingand/or the application may require Board consideration. The Board meets once every two months.Any application requiring Board review must be complete, with all materialsreceived by the Department, no later than 15 working days in advance of the nextscheduled Board meeting. Applications completed after that deadline will not beput on the Board's agenda.Any questions with regard to the processing of this application and other concernsplease contact the Board of Medical Examiners staff at (406) 444-6880 or e-mail usat DLIBSDHELP@MT.GOV

ECP app 6 Revised 07/19Page:3 of 8MONTANA BOARD OF MEDICAL EXAMINERSPO Box 200513301 South Park Avenue 4th FloorHelena, Montana 59620-0513PHONE: 406-444-6880E-MAIL: DLIBSDHELP@MT.GOVEMREMTFAX: 406-841-2305WEBSITE: EMT.MT.GOVAEMTParamedicPLEASE TYPE OR PRINT IN INK.(Please allow 10 working days for processing from the date that the Board has a complete routine application)1. FULL NAME:LastFirstMiddle2. OTHER NAME(S) KNOWN BY:3. BUSINESS NAME:4. BUSINESS ADDRESS:Street or PO Box #City and StateZip5. HOME ADDRESS:Street or PO Box #City and StateZipPREFERRED MAILING ADDRESS:BusinessHomeE-MAIL ADDRESS:6. TELEPHONE: ( )Business( )Home( )Fax7. SOCIAL SECURITY NUMBER:8. DATE OF BIRTH: PLACE OF BIRTH: FEMALECity/State9. LICENSEE NAME:(State your name as it should appear on the license if granted.)MALE

ECP app 6 Revised 07/19Page:4 of 810. Have you ever previously applied for a license to practice in Montana?If es, give date and results.Type of LicenseDatesResults of application Yes 1R Licensure #PERSONAL HISTORY QUESTIONSIMPORTANT INSTRUCTIONS AND NOTICE Please read the following questions carefully. Giving an incomplete or false answer isunprofessional conduct and may result in denial of your application or revocation of your license.See, 37-1-105, MCA.You have a continuing duty to update the information you provide in your application and supplemental responses, including while your application is pending and after you are granted alicense. Upon submittal of your application form, for every “yes” answer provided, you will receive arequest for specific information or documents associated with the question. Your application isnot complete until staff receive all information requested.PERSONAL HISTORY QUESTIONS11.Have you ever had any license, certificate, registration, or other privilegeto serve as a volunteer or practice a profession denied, revoked, suspended, orrestricted by a public or private local, state, federal, tribal, religious, or foreignauthority?12.Have you ever surrendered a credential like those listed in number 11, inconnection with or to avoid action by a public or private local, state, federal,tribal, religious, or foreign authority?13.Have you ever resigned to avoid discipline, been suspended, or beenterminated from a volunteer or employment position?14.Have you ever been required to participate in a behavioral modification orassistance program in lieu of suspension or termination from a volunteer oremployment position?Yes NoYes NoYes NoYes No

ECP app 6 Revised 07/19Page:5 of 815.Have you ever withdrawn an application for any professional license?16. As of the date of this application, are you aware of any pendingcomplaint, investigation, or disciplinary action related to any professionallicense you hold?17. Are you under a current order that remains unsatisfied (e.g., finesunpaid, probation not concluded, conditions unmet?)Yes NoYesNo HV 1RNote on Questions 18 and 19:Applicants who disclose medical, physiological, mental, or psychological conditions orchemical substance use in Question 18 or 19 may qualify for participation in the MontanaProfessional Assistance Program. Please visit the board website for more informationabout this program. "Chemical substances" include alcohol, drugs, or medications,whether taken legally or illegally.18. Do you have any medical, physiological, mental, or psychologicalcondition which in any way currently (within the last 6 months) impairs orlimits your ability to practice your profession or occupation with reasonableskill and safety?YesNo19. Do you currently (within the last 6 months) use one or more chemicalsubstances in any way which impairs or limits your ability to practice yourprofession or occupation with reasonable skill and safety?YesNoThe following information is provided for Question 20 below:A criminal conviction may not automatically bar you from receiving alicense. For more information about how a criminal conviction may impactyour application, consult the board or program website.

ECP app 6 Revised 07/19Page:6 of 820.Have you ever been convicted, entered a plea of guilty, no contest, or a similarplea, or had prosecution or sentence deferred or suspended as an adult or “juvenileconvicted as an adult” in any state, federal, tribal, or foreign jurisdiction?21.Are you now subject to criminal prosecution or pending criminal charges?22.Have you ever been disciplined, censured, expelled, denied membership orasked to resign from a professional society or organization?23.Have you ever had a civil judgment entered against you in a lawsuit forincompetence, negligence, or malpractice in practicing any profession?24.Have you ever been disqualified from working with children, elderly persons,mentally ill persons, or other vulnerable persons?25.Have you ever been placed on probation, restricted, reprimanded, suspended,revoked, resigned in lieu of action against you, or had other action taken against youby any hospital, clinic, health care facility, group medical practice, healthmaintenance organization, or third-party insurance provider, including Medicare andMedicaid?26.Are you currently on an exclusion list by the Office of Inspector General (OIG)for the U.S. Department of Health and Human Services prohibiting you from workingin a facility receiving federal funding?StateLicense # and TypeDate IssuedExpiration DateRequestedState verificationLicensure MethodExamExam Endorse Other HV1o Endorse Other es1oOther es1oExam Endorse Other es1oExam Endorse Other es1o

ECP app 6 Revised 07/19Page: 7 of 8MONTANA BOARD OF MEDICAL EXAMINERSPO Box 200513301 South Park Avenue 4th FloorHelena, Montana 59620-0513PHONE: 406-444-6880E-MAIL: DLIBSDHELP@MT.GOVFAX: 406-841-2305WEBSITE: EMT.MT.GOVAFFIDAVITI authorize the release of information concerning my education, training, record,character, license history and competency to practice by anyone who might possesssuch information to the Montana Board of Medical Examiners. I hereby declare underpenalty of perjury the information included in my application to be true and complete tothe best of my knowledge. In signing this application, I am aware that a falsestatement or evasive answer to any question may lead to denial of my application orsubsequent revocation of licensure on ethical grounds. I have read and am familiar withthe applicable licensure laws of the State of Montana and instructions to applicants forlicensing. I understand my recurring duty to comply with continuing educationrequirements as part of license renewal and my responsibility to maintaindocumentation for completed continuing education and refresher and my medicaldirector's authorization/attestation of continued competence (including endorsementskills) on a board-approved form which shall be made available to the board uponrequest. I accept the rules and procedures outlined in these documents as the basis formy application.Legal Signature of ApplicantDated